Healthcare-Associated Infections in a Tertiary Care Hospital: Significance of Patient Referral Practices

Introduction: Nosocomial infections, also known as healthcare-associated infections (HCAIs), are infections that a patient acquires while receiving healthcare services within 48 hours of admission to hospital. In high income countries, an average of 7% of hospitalised patients acquire a nosocomial infection. In low and middle income countries, however, prevalence rates can be as high as 30%. This is due to limited resources and supplies for infection control, inadequate training and lack of compliance with infection prevention and control regulations. Methods: A cross-sectional, hospital based study was conducted among patients admitted to a tertiary care facility in Tanzania. A semi-structured questionnaire was used to collect information from 134 patients in different wards. Correlation and multivariate regression analyses were performed to determine the association between the independent variables, i.e. chronic illness, invasive procedures, use of antibiotics and referral status, and the dependent variable, i.e. new symptom, and their level of significance. The significance level was set at P≤ .05. Results: A total of 134 patients participated in the study. Of the total number, 61% (n=82) of the patients were male and 43% (n=57) were referrals from other institutions. Fifteen percent (n=21) of the surveyed patients reported a new symptom. There was a positive correlation between referral status and invasive procedure with the occurrence of a new symptom. Multivariate analysis identified ‘referral status' as an independent significant factor positively associated with healthcare-associated infetions (P=.041). Conclusions: The results indicate a prevalence of 15.7% of healthcare-associated infections, which is unacceptably high for a tertiary care facility. Referral status was independently and significantly associated with HCAI. Improving patient referral patterns and hospital infection control can significantly reduce the risk of healthcare-associated infections.


BACKGROUND
H ealthcare-associated infections (HCAIs), also known as nosocomial infections or hospitalacquired infections (HAIs), are infections caused by bacteria, viruses or fungi that are acquired by a patient within 48 hours of admission to a healthcare facility, up to three days after discharge, or up to 30 days after surgery.Such infections are acquired by a patient while receiving healthcare services, i.e. diagnostic, therapeutic and preventive services.HCAIs are associated with the emergence of multidrugresistant microorganisms.This is a factor that leads to a significant burden of morbidity, mortality and associated costs for patients and their families. 1,2 ey are classified as catheter-associated urinary tract infections, central line-associated bloodstream infections, ventilator-associated pneumonia and surgical site infections (SSIs). 3Proposals for the definition and classification of healthcare-associated infections were first put forward in 2002 by Siegman-Igra et al and Friedman et al. 4,5 However, the definition of healthcare-associated infections is highly variable.[8][9] Healthcare associated infections are very unevenly distributed around the world.In high-income countries, approximately 15% of hospitalised patients and up to 37% of patients admitted to intensive care units develop HCAIs. 1,6,7 he pooled prevalence of HCAIs in Africa varies from 14.2% to 23.2%. 8,9 he average prevalence of HCAIs is 7% in high-income countries and 10% in llow-and-middle income countries (LMICs).][12][13] Inadequate resources, lack of infection prevention and control (IPC) training, and non-compliance with standard operating procedures are among the major causes of healthcare-associated infections in LMICs.In Ugandan hospitals, for example, an assessment of the role of medical devices in healthcare associated infections found that 9 out of 10 devices tested positive for contamination in at least 1 location and 2 out of 3 devices tested positive in at least two or more locations. 14The 3 most commonly isolated microorganisms were Bacillus species (53%), coagulase-negative staphylococci (15%) and Escherichia coli (13%).More worryingly, almost 30% of samples were resistant to 3 or more classes of antibiotics tested, including penicillin, tetracycline, glycylcycline and trimethoprim-sulfamethoxazole.Another study found that 93.4% of health facilities surveyed (30/32) did not have adequate infection control equipment or supplies. 15here were also reports of inadequate funding, training and low compliance with IPC. 16][19][20] Risk factors for HCAIs include a history of surgery or other invasive procedures, active or metastatic cancer, immunosuppression due to prolonged use of steroids, human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), radiotherapy and other causes, and transfer from another healthcare facility.The relationship between healthcare-associated infections and patient transfer patterns is only partially understood.In their study, Xia H. et al. argue that direct patient transfers between hospitals have only a limited impact on healthcare-associated infections and that readmission to the same hospital poses the greatest risk. 21Other reports show that reducing the number of transfers by diverting an average of 1.5 patients per hospital per day could reduce the spread of high-risk bacterial clones in hospital networks by 36%. 22,23 n contrast, another study found that patient diversion strategies alone could not reduce the prevalence of multidrug-resistant Enterobacteriaceae (MDR-E) at the level of a regional healthcare network. 24argeted hospital-based interventions focused on hospitals identified by network transmission patterns could reduce the spread of MDR-E by half. 24There are currently no reports on the role of patient referral patterns in healthcare-associated infections in Africa.The current study sought to identify factors influencing healthcareassociated infections in a tertiary referral hospital in Tanzania, taking into account patient referral patterns.The results of this study contribute to better patient referral practices and open new avenues for investigating the components of referral patterns that are specifically associated with HCAIs.

Study Area
The current study was conducted in a 553-bed tertiary health facility serving a population of over ten million people in Tanzania.The hospital is the only highly specialised health facility in the region and a referral centre for patients from eight administrative regions.

Study Design
A hospital-based cross-sectional study was conducted in a tertiary teaching hospital in Tanzania from July to August 2023.Patients from different wards -surgical, maternity, medical, E.N.T, intensive care and paediatric were randomly selected.The sample size was determined using Fisher's formula N= (Z2 x p(1-p))/e2 where N=number of minimum sample size, p=prevalence of nosocomial infections among inpatients.The recently reported point prevalence of HCAI in LMICs ranges from 7.67% to 12.76%. 10,11 he average prevalence of 10% reported by the World Health Organization was used in this study. 11Z= normal standard deviation with 95% confidence interval, i.e. 1.96, and e= standard maximum error, i.e. 0.05.A total of 134 eligible patients (patients admitted for more than 48 hours at the time of the study) participated in the study.Only time, person and place-oriented patients who were not critically ill were included in the study.

Data Collection
Data were collected using a semi-structured questionnaire, interviews and observational methods.Patients were given questionnaires translated into Swahili and asked to answer questions about length of hospital stay, invasive procedures, referral status, occurrence of a new symptom (fever, pus in the wound, cough, urinary symptoms) and use of antibiotics.The investigators supervised and observed the completion of the questionnaires and compared the patients' fever curves and other records with their responses.

Statistical Analysis
The data obtained were entered and analysed using MS Excel and SPSS (Statistical Package for the Social Sciences, IBM Corp., NY, USA) version 23.Categorical variables were expressed as numbers and percentages.Correlation and multivariate regression analyses were performed to determine the association of the independent variables, i.e. chronic disease, invasive procedures, antibiotic use and referral status, with the dependent variable, i.e. new symptom, and their levels of significance.The significance level was set at P≤ .05.

Ethical Approval and Informed Consent
Approval to conduct the study was granted by the Ethical Clearance Sub-Committee (ref.AB 458/482/02/476) of the University of Dar es Salaam, Mbeya University of Health and Allied Sciences.Informed consent was also obtained from all study participants.Interviews were conducted separately and responses were recorded anonymously.

Determinants of Nosocomial Infections
To gain further insight into the determinants of the development of new symptoms after admission, data on the categorical variables; chronic illness, use of antibiotics, invasive procedure and referral status were coded, analysed and tested against a dependent variable; new

DISCUSSION
Healthcare-associated infections represent a significant burden for patients, families and healthcare systems.The results of the current study show that the prevalence of healthcare-associated infections in the tertiary healthcare facility surveyed was 15.7%.9][20]25 In contrast to previous studies, the current study shows for the first time in an African country that patient referral patterns have a major impact on the transmission of HCAIs.Within the health care system, patients are referred to hospitals at different rates depending on the function and level of the hospital.This is likely to affect the prevalence of healthcare associated infections in different institutions.
It was also found that 10 out of 21 patients with new symptoms reported the presence of pus in the wound, which represents 7.5% of the patients surveyed.This is in line with another study conducted in Tanzania which found that 10.6% of patients surveyed (n=128) had a surgical site infection. 26In general, the incidence of surgical site infections in sub-Saharan Africa ranges from 6.8% to 26%. 27Surgical site infections are associated with prolonged hospital stay and increased risk of mortality.To reduce the burden of SSIs, the World Health Organization technical team developed the Global Guidelines for the Prevention of Surgical Site Infections in 2018, available at https://iris.who.int/bitstream/handle/10665/277399/9789241550475-eng.pdf?sequence=1.In summary, the results of the current study highlight the high prevalence of healthcare-associated infections in Tanzania and the importance of improving interventions to prevent surgical site infections.In addition, the results demonstrate for the first time in Africa the association between patient referral patterns and HCAIs.

CONCLUSIONS AND RECOMMENDATIONS
The results indicate a high prevalence of healthcareassociated infections in a tertiary referral hospital in Tanzania.I, therefore recommend an integrated and efficient approach that includes monitoring referral hospital linkages with other health facilities to improve patient referral patterns, and hospital infection control to reduce healthcare-associated infections.

Study Limitations
Although the current study found that healthcareassociated infections were more common in patients referred from other healthcare facilities, the study did not examine compliance with IPC rules by hospital staff.Bacteriological investigations and further research into factors related to patient referral behaviour were also not carried out, which would warrant a follow-up study.

FIGURE 1 :
FIGURE 1: Prevalence of common symptoms of Healthcare-Associated Infections

TABLE 1 :
Socio-demographic Characteristics of the Study Participants

TABLE 2 :
Correlation Between Independent Variables and the Occurrence of a New Symptom

TABLE 3 :
Significance Levels of the Categorical Variables with the Occurrence of a New Symptom